European Journal of Cardiovascular Medicine

Subtrochanteric fractures refer to fractures that occur within a 5 cm distance from the lesser trochanter in the proximal femur.   These fractures are a significant issue in orthopaedic surgery due to their intricate anatomy and the considerable mechanical forces exerted on this region.   Subtrochanteric fractures account for 25% of all hip fractures and 7-4% of all femur fractures   [1-5].   These fractures are generally the result of high-energy trauma in younger patients or low-energy falls in the elderly, and their care is critical for recovering mobility and function.   The treatment of subtrochanteric femur fractures has developed, with numerous fixation procedures being applied to obtain optimal outcomes.   Two primary fixation procedures are typically utilized in the surgical therapy of these fractures: intramedullary (IM) fixation and extramedullary (EM) fixation.   Intramedullary fixation includes the insertion of a rod into the marrow canal of the femur, giving internal support and stability.   This procedure is noted for its minimally invasive nature, shorter surgical duration, potential for early weight-bearing, biomechanical superiority, minimal invasiveness, and shortening of operation time, which have been noticed [2,4].   Extramedullary fixation, on the other hand, involves the use of plates and screws attached to the exterior surface of the bone, enabling firm fixing and stability, particularly in comminuted or complicated fractures.   Despite the widespread use of both procedures, there remains considerable controversy among orthopaedic surgeons regarding the superiority of one treatment over the other.   This disagreement originates from the varied biomechanical features, complication rates, functional outcomes, and healing timeframes connected with each approach.   Therefore, a detailed evaluation of intramedullary and extramedullary fixation is needed to determine the most effective technique for treating subtrochanteric femur fractures.   The goal of this study is to comprehensively assess the clinical results, complications, and biomechanical effectiveness of intramedullary and extramedullary fixation procedures in the treatment of subtrochanteric femur fractures.   By examining recent studies and clinical data, this study intends to provide a comprehensive knowledge of the advantages and limitations of each approach, ultimately aiding orthopaedic surgeons in making educated decisions for optimal patient care.   The purpose of this study is to analyze the effects of treatment of subtrochanteric femoral fracture utilizing IM (IM femoral nail, proximal femoral nail (PFN)) and EM (95° condylar plate, locked anatomical proximal femoral plate) fixation methods.

This retrospective study was carried out on 100 patients who had undergone surgery for subtrochanteric fractures at the Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India. This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Institutional Ethics Committee of Indira Gandhi Institute of Medical Sciences, Patna. The study comprised patients who visited our hospital for a prompt postoperative check-up and underwent X-ray imaging in the correct postures.

Inclusion Criteria:

• Patient Age: Adults aged 18 to 65 years.
• Fracture Type: Patients with confirmed subtrochanteric femur fractures within 5 cm distal to the lesser trochanter.
• Surgical Intervention: Patients who underwent either intramedullary (IM) or extramedullary (EM) fixation for their subtrochanteric femur fracture.
• Follow-up duration: Minimum follow-up period of 12 months post-surgery.
• Availability of Data: Complete medical records, including preoperative, intraoperative, and postoperative details, as well as radiographic images.

Exclusion Criteria:

• Age: Patients younger than 18 years and older than 65 years.
• Fracture Classification: Patients with periprosthetic, pathological, or open fractures of the subtrochanteric femur.
• Previous Surgery: Patients with a history of previous surgical intervention on the affected femur.
• Incomplete Data: Patients with incomplete medical records or insufficient follow-up data.
• Comorbid Conditions: Patients with severe comorbid conditions that significantly impact fracture healing, such as advanced diabetes, active cancer, or severe osteoporosis.
• Non-Surgical Treatment: Patients who received non-surgical treatment for their subtrochanteric femur fracture.

We excluded 20 patients from the study based on specific criteria: three had pathological fractures, six were either under 18 or over 65 years of age, three had associated pelvic, vertebral, or ipsilateral extremity fractures, and eight were lost to follow-up or deceased.

The remaining 100 patients were divided into two groups. Group A included 55 patients treated with intramedullary (IM) fixation, using either an IM femoral nail or a proximal femoral nail. Group B comprised 45 patients who underwent extramedullary (EM) fixation, utilizing either a 95° condylar plate or a locked anatomical proximal femoral plate.

Patient history and clinical data were obtained from the hospital’s records and digital imaging system. When fracture involvement of the piriform fossa was suspected, preoperative imaging included anteroposterior pelvic X-rays, bilateral hip, femur, and knee radiographs of the affected side, along with CT scans of the hip and femur. Prophylaxis against deep vein thrombosis, antibiotics, and skeletal traction were administered to 36 patients (36%), depending on the extent of fracture displacement. All surgeries were performed using a traction table, and patients were mobilized as soon as medically feasible.

We recorded demographic and clinical variables such as age, sex, side of fracture, cause of injury, anesthesia type, preoperative waiting time, duration of follow-up, fracture classification, and mechanical complications. Hip function was assessed using the Harris Hip Score (HHS), categorized as excellent, good, moderate, or poor. Due to limitations in physical examination for some patients, the original HHS was modified by relying on patient self-reporting, which has been shown to correlate strongly (99%) with the standard score [6,7]. The modified score was adjusted by multiplying by 1.1 and recalculated on a 100-point scale [8]. Postoperative radiographs were evaluated for varus-valgus angulation and procurvatum (flexion) deformity in the sagittal plane via the hospital’s digital imaging system, with angulations under 10° considered acceptable. Limb shortening in comminuted fractures was assessed by comparing radiographs to the contralateral femur in cases of displacement or overlap. Time to fracture union was analyzed by the presence of bridging callus in at least three of the four cortices on both anteroposterior and lateral views.

Statistical Analysis: The collected data was organized into a table using Microsoft Excel 2019. Subsequently, the data were transferred to GraphPad version 8.4.3 for further statistical analysis. Descriptive statistics were employed to calculate and display frequencies and percentages. Chi-square test or Fisher’s exact test for categorical variables, and paired t-test for continuous variables. A p-value of less than 0.05 was taken as a measure of significance.

The baseline demographic and clinical characteristics of the study population are summarized in Table 1. The study included 100 patients, [Group A: 55 and Group B: 45] with a mean age of participants in Group A was 47.77 years (±7.42), while Group B had a mean age of 46.20 years (±6.52), with no statistically significant difference between the groups (p = 0.270). Gender distribution was also comparable, with 30 males and 25 females in Group A, and 21 males and 24 females in Group B (p = 0.615). Regarding the side of involvement, 34 participants in Group A had right-sided conditions compared to 23 in Group B, whereas left-sided involvement was seen in 21 and 22 participants, respectively, with no significant difference (p = 0.282). Additionally, the average preoperative time was similar between the two groups, with 5.32 days (±0.99) in Group A and 5.08 days (±1.17) in Group B, showing no significant difference (p = 0.369). Overall, these findings indicate that the two groups were well matched in terms of demographic and clinical baseline characteristics. The most frequent cause of subtrochanteric fractures was falling from a height. The average follow-up period was 18.65 months. Local anesthesia was used for 64 patients, and general anesthesia was administered to 36 patients.

Table 1: Showing the comparison of baseline demographic and clinical characteristics of the study population

Subtrochanteric fractures in the study population were classified according to the Seinsheimer classification system. Among these, six fractures were categorized as type 2a, 40 as type 2b, eight as type 2c, 18 as type 3a, nine as type 3b, four as type 4, and 13 as type 5. Regarding the surgical fixation methods employed, intramedullary (IM) femoral nails were used in 35 patients (35%), proximal femoral nails (PFN) in 20 patients (20%), 95° condylar plates in 19 patients (19%), and proximal femoral anatomical plates in 26 patients (26%).

Table 2 and Figure 1 present the comparison of postoperative complications observed in both study groups. In terms of postoperative complications, Group A (IM) had slightly higher rates of delayed union (21.82% vs. 17.78%), non-union (5.45% vs. 2.22%), malalignment (14.54% vs. 11.11%), implant failure (10.91% vs. 4.44%), and limb shortening (9.09% vs. 8.89%) compared to Group B (EM). However, none of these differences reached statistical significance (p > 0.05). Interestingly, while no cases of infection were recorded in Group A, 2 patients (4.44%) in Group B experienced postoperative infections, with a proximal femoral locking plate, which was treated by removing the implants. Overall, although some differences in complication rates were observed between the two groups, most were not statistically significant.

Table 2: Showing the comparison of the complications in Group A and Group B.

Figure 1: Illustration of the comparison of the complications in study groups

Table 3 compares the complication rates between patients with and without malalignment. Among the 13 patients with malalignment, delayed union occurred in 6 cases, non-union in 2, and implant failure in 2. In contrast, among the 77 patients without malalignment, delayed union was seen in 14 cases, non-union in 2, and implant failure in 6. Statistical analysis showed no significant difference between the two groups across these complications, with a p-value of 0.665 for the overall comparison. Thus, the presence of malalignment did not appear to significantly influence the rates of delayed union, non-union, or implant failure. The average Harris Hip Score (HHS) for the general population was 86.5, with no significant difference between the groups in terms of HHS.

Table 3: Showing the comparison of the complication rate in patients with and without malalignment.

The optimal fixation technique for subtrochanteric femur fractures remains a matter of ongoing debate, with no clear consensus among orthopaedic surgeons. This clinical dilemma prompted us to undertake a comparative study evaluating the outcomes of intramedullary (IM) versus extramedullary (EM) fixation methods for managing these fractures. We aimed to assess and analyze the efficacy, benefits, and drawbacks associated with each approach in the context of clinical outcomes, reduction quality, union rates, and complication profiles.

Despite thorough analysis, our findings did not demonstrate a statistically significant difference between the two fixation modalities. Each technique possesses distinct advantages and limitations. Intramedullary nailing is associated with reduced soft tissue trauma, enhanced biomechanical support of the medial cortex, and superior load-bearing capacity. However, anatomical reduction may not always be precise due to the reliance on closed reduction techniques. In contrast, extramedullary plating allows for more accurate anatomical alignment, though it often necessitates extensive dissection, potentially increasing operative time, blood loss, and soft tissue complications. As such, the surgeon's individual expertise and preference remain pivotal in choosing the most appropriate treatment approach.

Subtrochanteric fractures are less frequently encountered than femoral neck or intertrochanteric fractures but present a unique set of challenges due to their anatomical and biomechanical characteristics. The proximal fragment is typically subjected to deforming forces that induce flexion and abduction, complicating the reduction process. Moreover, the subtrochanteric region acts as a major load-bearing zone, further complicating management. The scarcity of comparative studies specifically targeting this fracture type underscores the clinical relevance of our investigation. Our study aims to enrich the existing literature and guide clinical decision-making. Both treatment groups in our study achieved favorable clinical outcomes, aligning with existing evidence. Mirbolook et al. retrospectively studied 114 patients and found no significant difference between IM nails and proximal femoral locking compression plates in terms of clinical results [9]. Similarly, Cook et al. analyzed 244 subtrochanteric fractures—168 treated with IM implants and 75 with EM implants—and observed no significant disparity, except for a higher transfusion rate in the EM group [10]. Pakuts divided 26 patients into two groups (15 with dynamic condylar screws and 11 with gamma nails), reporting no substantial differences in clinical results or complications. However, he noted quicker recovery and earlier return to activity among patients treated with gamma nails [11]. Sowmianarayanan et al. employed finite element analysis to compare DHS, DCS, and PFN, concluding that all three implants behaved similarly under mechanical stress [12]. These findings resonate with our own results, reinforcing the notion that the superiority of one fixation method over another remains unproven. Umer et al. reported a 94% success rate using PFNs in the treatment of subtrochanteric fractures, recommending it for all types except Seinsheimer type IV [13]. Imerci et al. compared LISS plates and PFN in a cohort of 32 patients and found that consolidation occurred more slowly in the plate group, though Harris Hip Scores were higher. Importantly, no significant differences in complications or reoperations were observed [14].

The current trend toward IM fixation is likely influenced by its biomechanical advantages and recent technological advancements in nail design. EM plating techniques, while still relevant, are now more commonly used for managing complications such as malunion and non-union. In our cohort, four cases of non-union were observed, most of which necessitated revision surgery with extramedullary fixation. This underscores the need for careful case selection and surgical precision. Proper alignment is crucial in subtrochanteric fracture management. Inadequate reduction may lead to mechanical failure and poor outcomes. White et al. examined 122 cases managed with IM nails and found higher rates of non-union and implant failure when proper reduction was not achieved [15]. In our study, comparison between patients with malalignment (n=13) and those with satisfactory alignment (n=77) revealed no significant differences in union rates or implant failures. Zhou et al. reported on 76 patients treated with IM devices; only five underwent successful closed reduction, with the remainder requiring mini-open approaches. All but one patient achieved union, with one delayed case [16]. Riehl et al. treated 35 subtrochanteric fractures using IM nails, reporting a 97% union rate without secondary surgical intervention. However, seven patients showed >10° angulation, of which six experienced delayed union and one non-union [17]. Lee et al. compared closed and minimally open reductions for IM nailing, finding higher rates of malalignment and non-union in the closed group. They advocated for mini-open techniques when closed reduction is suboptimal [18]. Malalignment often results in proximal fragment varus angulation, flexion, and external rotation, leading to limb shortening and abductor insufficiency due to trochanteric migration [19]. The DCS implant remains a frequently employed option, especially in oblique or transverse fractures with small proximal fragments. Neogi et al. reported favorable outcomes in 40 cases managed with this implant [20]. In our study, we used a 95° DCS plate in 14 patients, with one case of delayed union due to plate failure. Rohilla et al. treated 43-part subtrochanteric fractures using DCSs and observed neither non-union nor implant failure [21]. Proximal femoral locking compression plates offer a viable alternative to DCS in cases involving small or unstable fragments, with prior studies showing promising outcomes [22–24]. Despite the advantages of anatomical reduction, EM fixation is associated with longer surgical times, increased blood loss, and elevated infection risk. Conversely, IM nails are minimally invasive and biomechanically superior in many cases, although they carry a higher risk of malalignment, especially when performed without adequate visualization. The clinical implications of such malalignment remain open to interpretation. Our results reinforce the notion that both IM and EM techniques can yield satisfactory outcomes, with no clear superiority of one over the other. Both Groups A and B demonstrated comparable clinical performance. Larger, prospective studies with longer follow-up periods are necessary to provide more definitive conclusions. Presently, the surgeon’s judgment, skill, and comfort with the chosen technique appear to be decisive factors.

The retrospective design of our study introduces inherent limitations, including the potential for data collection bias. Patients without appropriately positioned radiographs were excluded, and although measurements were standardized, positional variation may have influenced the assessments. However, such variability likely occurred similarly in both cohorts. A notable imbalance in group sizes was observed due to a general preference for IM fixation. All surgeries were performed at the same institution but by different surgeons. Implant uniformity was not maintained across all patients: the IM group included femoral nails and PFNs, while the EM group included 95° condylar plates and locking anatomical plates. This lack of standardization is a recognized limitation. A prospective, randomized clinical trial with consistent surgical technique and long-term follow-up would better delineate the optimal fixation strategy for subtrochanteric fractures.

Both intramedullary (IM) and extramedullary (EM) fixation methods are effective for managing subtrochanteric femur fractures, each with its own advantages and limitations. IM fixation offers better biomechanical support with less soft tissue disruption, while EM fixation provides more accurate anatomical alignment but with increased surgical risk. Our study found no significant difference in outcomes, indicating that both techniques are viable options, and the choice should be based on individual case factors and surgical expertise.

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